LTC Reviews



Sending Invitations

Booking Appointments

Sending Reminders

Pre-assessment Questionnaires

Initial Review & Tests

Follow-Up Review

Interim Reviews

Exception Reporting

LTC Reporting

LTC Review - FAQ

Ardens offers a comprehensive approach to Long Term Conditions Reviews. Clinical reports & months of birth are used to send invitations to patients and a single template can then be used to perform the relevant reviews. Please watch the latest webinar below for an overview of how this system works.

The online resources here should guide you through the LTC process but we also advise you to book some LTC Review training at your surgery for all your staff too.

LTC Review Conditions Included 

You can choose between recalling just QOF or QOF + Best Practice conditions, and we also have separate searches to manage your dementia, learning disability, care home and housebound patients. 

The conditions we include in our searches are as follows:


Conditions Dementia, Learning Disability
HousingCare home resident or housebound




HTN + Pulse:    HTN, AF
Cardiovascular:CHD, CHF, PAD, CVA/TIA
Diabetes:DM1, DM2, NDH/Pre-Diabetes, Gestational Diabetes
Renal:CKD 1-5
Mental Health:SMI
Respiratory:Asthma (if bronchodilator issued in last year), COPD
Other:Rheumatoid Arthritis, Epilepsy (if antiepileptics issued in last year)


Cardiovascular:CVD-Primary Prevention (on statin or QRISK2/3 >10%), Familial Hypercholesterolaemia
Endocrine:Hyperthyroidism, hypothyroidism, primary hyperparathyroidism
Gastrointestinal:Coeliac Disease, Post-Bariatric Surgery
Haematology:Monoclonal Gammopathy of Unknown Significance (MGUS)
Liver:Non-Alcoholic Fatty Liver Disease (NAFLD + NASH)
MSK:Gout + on ULT

Please note:  At the end of May 2024, we will be updating our LTC and Best Practice reports to include patents that also have PCOS and Bronchiectasis.  The Initial Review and Follow Up tabs on the LTC template have already been updated with these changes.

To view our recent Live webinar explaining the new LTC Process in more detail, please click on the below video:

LTC Pre-Appointment Tests Included 

For a summary of the pre-appointment tests that are requested, please see here.

Sending Invitations Using Reports

Ardens use reports, not recalls, for sending invitations as reports are not reliant on users adding/superseding/removing recalls. They also do not require time to maintain if a new patient registers or a practice merges. Reports also ensure only a single invitation is sent to a patient with multiple co-morbidities.

Please note:

  • A new patient must be reviewed at the time of registration. 
  • A new diagnosis must be reviewed at the time of diagnosis. 
  • Good data quality is required for new & resolved diagnoses (see here
  • The system is reliant on a single read code Xaagy – Chronic disease management annual review completed being added after the annual review is completed. This is to ensure that 2nd or 3rd invites are not sent out. 
  • Whilst invitations are only sent annually, some conditions require more frequent review. Additional reviews should be booked at the time of the previous appointment. 
  • This is not an all-encompassing solution for every condition & circumstance. Clinical expertise and judgement is still required at all stages. It is the practice’s responsibility to check the reports/templates/alerts prior to commencing the LTC review process.
  • In order to use the appropriate QOF Condition invitation codes; please refer to our changes to the LTC QOF Invitation Codes support article for more details.

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